scholarly journals Current Strategies in the Treatment of Intracranial Large and Giant Aneurysms

2021 ◽  
pp. 19-26
Author(s):  
Matthias Gmeiner ◽  
Andreas Gruber
Keyword(s):  
Treatment Strategies ◽  
High Volume ◽  
Mass Effect ◽  
Artery Occlusion ◽  
Active Management ◽  
Definitive Treatment ◽  
Parent Artery ◽  
Giant Aneurysms ◽  
Parent Artery Occlusion ◽  
Large And Giant Aneurysms

AbstractIntroduction: Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery.Methods: The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases illustrating possible treatment strategies.Results: In view of the poor natural history, active management using multiprofessional individualized approaches is required to achieve aneurysm occlusion, relief of mass effect, and obliteration of the embolic source. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available to achieve definitive treatment with acceptable morbidity.Conclusions: Patients harboring such lesions should be managed at high-volume cerebrovascular centers by multidisciplinary teams trained in all techniques of open and endovascular neurosurgery.

Abstract 1122‐000071: Large and Giant Intracranial Aneurysms, Clinico‐Radiological Outcome and Predictors with Flow Diverter Stent

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Islam El Malky ◽  
Ayman Zakaria ◽  
Essam Abdelhameed ◽  
Hazem Abdelkhalek
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Artery Occlusion ◽  
Parent Artery ◽  
Giant Aneurysms ◽  
Complex Aneurysms ◽  
Parent Artery Occlusion ◽  
Large And Giant Aneurysms ◽  
Flow Diverters

Introduction : Endovascular treatment for large and giant aneurysms has included either a reconstructive approach or a deconstructive approach by parent artery occlusion. 1,2 Stent‐assisted coiling and balloon‐assisted coiling were alternative techniques developed to deal with such complex aneurysms, but studies have shown less expected efficacy. This study aims to assess the safety and efficacy of the flow diverter stents for treating large and giant intracranial aneurysms and to examine possible predictors for radiological and clinical outcomes such as location and presence of branching artery, bifurcation, and adjuvant coiling. Methods : This study had been conducted on 65 consecutive patients with 65 large and giant aneurysms (size ≥ 10 mm) treated with flow diverters; Periprocedural complications were reported in all patients and clinical outcomes. Follow‐up angiography was done for 60 patients (92.3%) at 12 months. Results : The study included 65 patients who harbored 65 aneurysms. The median age was 55.5 years (IQR: 44.25 ‐ 62.75 years), the female represented 70.8 % of all patients. The clinical presentation had been reported (Headache, cranial nerve palsy, motor deficit, seizures, and visual field defect in 40 patients (61.5%), nine patients (13.8%), seven patients (10.8%), five patients (7.7%), and four patients (6.2%) respectively. The vascular risk factors had been reviewed (HTN, DM, smoking, and Hyperlipidemia in 25 patients (9.2%), Six patients (9.2%), sixteen (24.6%), and 10 patients (15.4%) respectively). The median size of aneurysms was 16.4 mm (IQR: 12.50 ‐ 23.85 mm) and the median neck width was 7.15 mm (IQR: 5.85‐10.24 mm). Fourteen aneurysms (21.4 %) had previous treatment, eleven aneurysms (16.9%) were treated by coils only, one case (1.5%) by assisted procedure, one case (1.5%) by previous FDS, and parent artery occlusion in one case (1.5%). Complete occlusion in 50 from 60 aneurysms (83.4%), neck remnant in 8 aneurysms (13.3%), and sac remnant in two aneurysms (3.3%). Periprocedural problems were encountered in 14 patients (21.5%) with morbidity in six patients (9.2%) and mortality in one patient (1.5%). Univariate and multivariate logistic regression analysis was used to discover possible predictors of combined mortality and morbidity and occlusion in Table (1). Conclusions : From this study, it could be concluded that Endovascular treatment of the large and giant aneurysms with flow diverters represents a safe method for treating this kind of complex intracranial aneurysms. Complex aneurysms with branching artery and bifurcation were associated with aneurysm persistence and complications respectively while the location of the aneurysm was the only predictor for clinical outcome.

Parent artery occlusion is not obsolete in giant aneurysms of the ICA. Experience with very-long-term follow-up

2010 ◽  
Vol 53 (12) ◽  
pp. 973-982 ◽  
Author(s):  
Frédéric Clarençon ◽  
Fabrice Bonneville ◽  
Anne-Laure Boch ◽  
Lise Lejean ◽  
Alessandra Biondi
Keyword(s):  
Artery Occlusion ◽  
Parent Artery ◽  
Giant Aneurysms ◽  
Parent Artery Occlusion ◽  
Long Term Follow Up

Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992

1997 ◽  
Vol 87 (2) ◽  
pp. 141-162 ◽  
Author(s):  
Charles G. Drake ◽  
Sydney J. Peerless
Keyword(s):  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Mass Effect ◽  
Artery Occlusion ◽  
Parent Artery ◽  
Anterior Circulation ◽  
Content Type ◽  
Parent Artery Occlusion ◽  
Collateral Vessels ◽  
Proximal Occlusion

✓ The paucity of information about giant fusiform intracranial aneurysms prompted this review of 120 surgically treated patients. Twenty-five aneurysms were located in the anterior and 95 in the posterior circulation. Six patients suffered from atherosclerosis and only three others had a known arteriopathy. The remaining 111 patients presented with aneurysms resulting from an unknown arterial disorder; these patients were much younger than those harboring atherosclerotic aneurysms. Mass effect occurred in only 50% of cases and hemorrhage in 20%. Eight aneurysms caused transient ischemic attacks. Hunterian proximal occlusion or trapping were dominant among the treatment methods. In contrast to the management of giant saccular aneurysms, the usual thrombotic occlusion of a giant fusiform aneurysm after proximal parent artery occlusion requires the presence of two collateral circulations to prevent infarction, one for the end vessels and another for the perforating vessels that arise from the aneurysm. Although there was some reliance on the circle of Willis and on collateral vessels manufactured at surgery, the extent of natural leptomeningeal and perforating collateral, thalamic, lenticulostriate, and brainstem vessels was astonishing and formerly unknown to the authors. Good outcome occurred in 76% of patients with aneurysms in the anterior circulation; two of the six cases with poor results included patients who were already hemiplegic. Ninety percent of patients with posterior cerebral aneurysms fared well. Only 67% of patients with basilar or vertebral aneurysms had good outcomes, although more (17%) of these patients were in poor condition preoperatively because of brainstem compression.

Stent-Assisted Parent Artery Occlusion of Giant Cerebrovascular Aneurysms to Avoid Mass Effect

2009 ◽  
Vol 19 (4) ◽  
pp. 370-374 ◽  
Author(s):  
Syed I. Hussain ◽  
John R. Lynch ◽  
Thomas Wolfe ◽  
Brian-Fred Fitzsimmons ◽  
Osama O. Zaidat
Keyword(s):  
Mass Effect ◽  
Artery Occlusion ◽  
Parent Artery ◽  
Parent Artery Occlusion

scholarly journals Intracranial Fusiform and Circumferential Aneurysms of the Main Trunk: Therapeutic Dilemmas and Prospects

2021 ◽  
Vol 12 ◽  
Author(s):  
Yunbao Guo ◽  
Ying Song ◽  
Kun Hou ◽  
Jinlu Yu
Keyword(s):  
Open Surgery ◽  
Cerebral Arteries ◽  
Treatment Strategies ◽  
Artery Occlusion ◽  
Parent Artery ◽  
Main Trunk ◽  
Vertebrobasilar System ◽  
Parent Artery Occlusion ◽  
Therapeutic Choice ◽  
Weak Points

Intracranial fusiform and circumferential aneurysms (IFCAs), especially those located on the main trunk, are uncommon and difficult to manage. Currently, literature focused on IFCAs on the main trunk of cerebral arteries is lacking. The treatment of IFCAs is still under debate. Therefore, in this review, we further explore the treatment of this complicated entity. In addition, we also present some interesting cases. Based on the literature review and our experience, we found that IFCAs are often located in the vertebrobasilar system and that ruptured or large symptomatic IFCAs are associated with increased mortality and higher rebleeding rates. The treatment strategies for IFCAs can be classified as deconstructive and reconstructive methods via open surgery and/or endovascular treatment (EVT). Currently, EVT is a popular method and the main therapeutic choice. In particular, flow diversion has revolutionized the treatment of IFCAs. Parent artery occlusion (PAO) with or without revascularization may still be considered a suitable choice. Complex IFCAs that cannot be resolved by EVT can also be treated via open surgery with or without extracranial–intracranial bypass. Targeted embolization for the weak points of IFCAs is a temporary or palliative choice that is rarely used. In summary, despite complications, both surgical treatment and EVT are effective options for appropriately selected cases. Due to the development of endovascular implants, EVT will have better prospects in the future.

Thrombotic Intracranial Aneurysms: Classification Scheme and Management Strategies in 68 Patients

Neurosurgery ◽  
2005 ◽  
Vol 56 (3) ◽  
pp. 441-454 ◽  
Author(s):  
Michael T. Lawton ◽  
Alfredo Quiñones-Hinojosa ◽  
Edward F. Chang ◽  
Timothy Yu
Keyword(s):  
Classification Scheme ◽  
Management Strategies ◽  
Treatment Strategies ◽  
Artery Occlusion ◽  
Morbidity Rate ◽  
Parent Artery ◽  
Solid Mass ◽  
Parent Artery Occlusion ◽  
Conceptual Clarity ◽  
Surgeon Experience

Abstract OBJECTIVE: Thrombotic aneurysms are a diverse collection of complex aneurysms characterized by organized intraluminal thrombus and solid mass. Consequently, their treatment often requires techniques other than conventional clipping, such as thrombectomy with clip reconstruction or bypass with parent artery occlusion. A single-surgeon experience with thrombotic aneurysms was analyzed to determine optimal treatment strategies. A classification scheme was devised on the basis of aneurysm, thrombus, and lumen morphology to relate these anatomic features to surgical therapy. METHODS: Sixty-eight patients with thrombotic aneurysms were managed during a period of 6.25 years. Thrombotic aneurysms were classified into six types: concentric (n = 17, 25%), eccentric (n = 14, 21%), lobulated (n = 2, 3%), complete (n = 2, 3%), canalized (n = 17, 25%), and coiled (n = 16, 24%). RESULTS: Aneurysm management consisted of direct clipping (n = 22, 32%), thrombectomy-clip reconstruction (n = 18, 26%), bypass-occlusion (n = 20, 29%), other (n = 6, 9%), or observation (n = 2, 3%). Complete angiographic obliteration was achieved in 97% of patients, and 47% of aneurysms were thrombectomized. The surgical mortality rate was 6%, and the permanent neurological morbidity rate was 7%. Overall, 87% of patients were improved or unchanged at follow-up, with 79% reaching a Glasgow Outcome Scale score of 5 or 4. Management strategy was influenced by thrombotic aneurysm type, but patient outcome was not. The best results were observed in patients treated with direct clipping and bypass-occlusion. CONCLUSION: Despite their solid mass, one-third of thrombotic aneurysms can be treated surgically with conventional clipping. Direct clipping is associated with the best surgical results, and the proposed classification scheme identifies thrombotic aneurysms that may be clippable. Patients with unclippable thrombotic aneurysms had more favorable results when treated with bypass and aneurysm occlusion than with thrombectomy and clip reconstruction. The classification scheme may provide conceptual clarity and therapeutic guidance with preoperative and intraoperative decision making.

scholarly journals Embolic stroke secondary to spontaneous thrombosis of unruptured intracranial aneurysm: Report of three cases

2015 ◽  
Vol 22 (2) ◽  
pp. 196-200 ◽  
Author(s):  
Antonio Arauz ◽  
Hernán M Patiño-Rodríguez ◽  
Mónica Chavarría-Medina ◽  
Mayra Becerril ◽  
José G Merino ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Aneurysms ◽  
Mass Effect ◽  
Artery Occlusion ◽  
Stroke Recurrence ◽  
Parent Artery ◽  
Spontaneous Thrombosis ◽  
Unruptured Intracranial Aneurysm ◽  
Risk Of Bleeding ◽  
Parent Artery Occlusion

Intracranial aneurysms uncommonly present with ischemic stroke. Parent artery occlusion due to local extension of the luminal thrombus, aneurysms ejecting emboli to distal arteries, or increased mass effect have been described as possible pathogenic mechanisms. Guidelines for the management of these patients are absent. We present the clinical outcome and radiological characteristics of three patients with spontaneous thrombosis of intracranial aneurysms as a cause of ischemic stroke. This information is relevant given the possible benign history in terms of stroke recurrence and risk of bleeding.

Challenges in the Endovascular Treatment of Giant Intracranial Aneurysms

Neurosurgery ◽  
2006 ◽  
Vol 59 (suppl_5) ◽  
pp. S3-113-S3-124 ◽  
Author(s):  
Nestor R. Gonzalez ◽  
Gary Duckwiler ◽  
Reza Jahan ◽  
Yuichi Murayama ◽  
Fernando Viñuela
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Clinical Manifestations ◽  
Artery Occlusion ◽  
Parent Artery ◽  
Endovascular Techniques ◽  
Giant Aneurysms ◽  
Giant Intracranial Aneurysms ◽  
Parent Artery Occlusion ◽  
Hemodynamic Characteristics

Abstract OBJECTIVE: Giant intracranial aneurysms present unique therapeutic intricacies. The purpose of this study was to evaluate the anatomic and hemodynamic characteristics of these lesions and the current endovascular and combined surgical and endovascular techniques available for their treatment. METHODS: A review of the literature and the personal experiences of the authors with endovascular treatment of giant aneurysms are presented. This review included anatomic and hemodynamic features and analysis of the diverse endovascular techniques that have been reported for the management of these aneurysms. RESULTS: Anatomic features that create particular challenges in the therapeutic approach of giant aneurysms include size, shape (saccular, fusiform, serpentine), neck dimensions, branch involvement, intraluminal thrombosis, and location. Hemodynamic characteristics that affect endovascular treatment are lateral or terminal aneurysm type of flow and embolic material placement (inflow versus outflow aneurysmal region). The current endovascular therapeutic approaches include parent artery occlusion, trapping, endosaccular embolization with or without adjunctive techniques such as balloon-assisted or stent placement, and combined surgical and endovascular approaches, mainly with surgical revascularization and endovascular occlusion. CONCLUSION: Although there are a wide variety of endovascular therapeutic options for the treatment of giant intracranial aneurysms, none of the current techniques is completely successful and free of complications in the management of these complex lesions. A detailed and individualized analysis of each case in conjunction with sufficient understanding of the anatomy and hemodynamics of a particular aneurysm should guide the therapeutic decision. Further research advances will assist in elucidating the factors predisposing to genesis, progression, and aggressive clinical manifestations of these giant lesions.

Endovascular Treatment of Posterior Circulation Fusiform Aneurysms: Single-Center Experience in 31 Patients

Neurosurgery ◽  
2011 ◽  
Vol 69 (2) ◽  
pp. 274-283 ◽  
Author(s):  
Guy Raphaeli ◽  
Laurent Collignon ◽  
Olivier De Witte ◽  
Boris Lubicz
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Endovascular Treatment ◽  
Mass Effect ◽  
Artery Occlusion ◽  
Posterior Circulation ◽  
Parent Artery ◽  
Excellent Outcome ◽  
Parent Artery Occlusion ◽  
Asymptomatic Patients ◽  
Cranial Nerve Palsies

Abstract BACKGROUND: Posterior circulation fusiform aneurysms are rare but difficult to treat. OBJECTIVE: To report our experience with endovascular treatment of posterior circulation fusiform aneurysms. METHODS: A retrospective review of our prospectively maintained database identified all posterior circulation fusiform aneurysms treated by endovascular approach over a 6-year period. Clinical charts, procedural data, and angiographic results were reviewed. RESULTS: From March 2004 to March 2010, 31 patients were identified: 11 asymptomatic patients, 9 who presented with a subarachnoid hemorrhage, 6 with a stroke, and 5 with a mass effect. All but 1 patient (97%), who died before being treated, were successfully treated by parent artery occlusion (n = 10), stenting plus coiling (n = 10), or stenting alone with conventional or flow-diverting stents (n = 10). Twenty-two patients showed a good or an excellent outcome (73%); 3 had a fair or a poor outcome (10%); and 5 patients died (17%). These 8 patients initially presented with severe subarachnoid hemorrhage or mass effect. Procedure-related morbidity includes only one patient who kept a worsening of cranial nerve palsies. There was no definitive procedure-related morbidity or mortality. Immediate aneurysm occlusion was incomplete in 20 cases (67%) and complete in 10 cases (33%). Mean follow-up of 20 months in 23 patients showed 12 further thromboses, 9 stable results, and 2 flow reductions. Final results included 19 complete occlusions (83%) and 4 incomplete occlusions (17%). CONCLUSION: Posterior circulation fusiform aneurysms may be treated by different endovascular approaches with satisfying clinical and anatomical results in most cases. However, patients who present with severe subarachnoid hemorrhage or mass effect still have a poor prognosis.

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